MANAGEMENT MEETING ISO 9001 Present: Joe Hoare Clodagh Hanratty Bernard Lennon Niamh Mooney Louise Naughton

Date: May and June 2009. (Last meeting 17th June 2009) Minutes: 1. Minutes of previous meetings and General discussion items. 1. Gerry Mc Namara retired since the last Management Review meeting. 2. Clodagh Hanratty has returned form leave. 3. Procedures have been developed and approved for the operation of the QMS in Clare and Tipperary, these procedures have been incorporated into the Documented Quality System.

2. SGS Last Audit report findings The last external SGS audit was a re certification audit it was conducted by Noel Mc Keon on 18th December 2008. The following were the finding raised from this audit.  1. Technical Services Department should be replaced by Estates Management in Quality Manual and other relevant documentation 2. Consider the need to have several hard copies of the Quality Manual as it is available on the network. 3. 5.5.2 Management Representative needs to be updated as Gerry has left 4. Quality Policy needs to be re-approved 5. Organisation chart to be updated 6. Form XXX is referred to in the the Document control procedure, please clarify (also in control of NC procedure) . 7. There are 2 procedures numbered 302, management review and record control, please clarify, record control looks like an old format 8. P305 Audit programme Form XXX, please clarify, also audit summary sheet XXX.

Corrective action requests number 58 to 66 – were raise from the last SGS audit dated Dec 08. These issues have all been addressed and closed out.

Action: None.

3. Customer Feedback/ Comments It was decided at the last Management Review Meeting that Customer Feedback will be collected in future is when a project is completed, the person in charge of the project will contact the Customer and collect and document information relating to the overall satisfaction of the job. This information will be forwarded to Niamh for filing in a folder and subsequently used at the Management Review Meeting. See attached Customer Feedback procedure and customer Responses . Action: None.

4. ISO Meetings/ Communications Regular meeting and communication took place throughout the year in relation to ISO 9001:2008. A major piece of work this year was reviewing all the quality procedures and putting them on electronic format. This has now been completed. Action: None.

6. Design and Development Action from previous Management Review Meeting: Louise to review Quality Manual to refer to drawing office in the Quality Manual under section 7.3. this is now completed and 7.3 Design and Development is no longer an exclusion in the documented quality system. Action: None.

7. Car review All Car’s were reviewed that following CAR’s are still open. 

CAR No 5 – Regional Hospital – lack of space, Action: Gerry to follow up, submission for capital plan Agreed Completion Date: 30th June 2008  CAR No 31 – Drawing Office (Procedure/ flow chart being developed see separate section of these minutes) Work still underway new date set for completion 1st November 2009.  CAR No 39 - ASSET REGISTER STILL IN PROGRESS Nenagh. Reviewed on 2nd June 2009. Action: Louise to Review during the internal audit planned for Sept 09.  CAR No 40 - ASSET REGISTER STILL IN PROGRESS Ennis. Needs to be checked at internal audit planned for 12th June 2009. This car was closed ount and a new one raised on the 12th June CAR no.67.  CAR No 41 to 46, 56,57 – raise from recent internal audits will be reviewed at the next Management Review Meeting planned May/ June/ July 2010.

8. Internal audits The internal audit schedule for 2009 is attached to this document. This was reviewed at this meeting no concerns found. Internal Audit have been completed in the following areas: Section Fire Safety Quality Management Maintenance Regional Hospital Capitol Projects Maintenance Ennis Gap analysis audit to ISO 9001:2008

Date Completed Started but not completed. 18th and 19th March 09 18th May 09 Started but not completed. 12th June 2009 19th March 09

CAR raised No Yes Yes No No. Yes.

The finding of the reports was discussed. Car’s were raised for all nc’s identified during the audit. Action: None.

9. Management Review (Yearly) Meeting Action: Next Management Review meeting is due May/ June/ July2010

10. New/ revised procedures Over the course of the last 12 months, all the procedures in the Quality Management System were reviewed and updated where necessary. The Internal audits also called for a lot of procedure to be updated. The full documented system is now set up electronically and will be available shortly on the server for Estates employees to view. A master document list was also drafted stating the latest version of each procedure. See list attached.

Action: None.

11. Effectiveness of training Carried out over the previous 12 months. A car has been raised to implement more controls at local level for training records, planning of training and review of the effectiveness of training carried out. CAR no 37 which is open.

12. NEW REGULATIONS/ STANDARDS/ EU/ GOVERNMENT ??????? Gerry was at a national meeting on a draft procedure for waste disposal. Action: Gerry to update us at the next meeting with regard to this new draft. Agreed Completion Date: None

Clinical engineering have decided to go and implement ISO 13485. This project is will resume end 09/10. Action: Louise to work with Bernard Ryan on ISO 13485 implementation. Agreed Completion Date: July 2010.

13. Objectives and targets Measure of projects completed Action: John and Margaret to email Joe and Clodagh Review of jobs on going. Agreed Completion Date: Introduction of new/ revised procedures (See separate section in this report) New Standards etc. (See separate section in this report)

14. Opportunities for improvement. 

The Capital projects drawing office have started to colour code file inn year order. This is a big asset and will help when finding documents in future. 2008- yellow, 2009 – blue.  Review of all documented procedures is planned. See attachments of this report. Action assigned: as per documents attached. Expected completion date: Oct 09

15. Quality Policy Review. We reviewed the quality Policy at this meeting. Action: None. Next Management Review Meeting planned May/ June/ July 2010.

CUSTOMER FEEDBACK PROCEDURE (NEW 2009).

Customer Feedback

Procedure No. 307

Prepared by Reviewed by

Corporate Authorisation

Print Name Louise Naughton Niamh Mooney

Title Quality Assurance Consultant Asst Fire & Safety Officer

Date 09/04/09

J.Hoare

Estates Officer.

09/04/09

09/04/09

INTRODUCTION To define the system in place to collect and utilize Customer feedback.

Scope This process outlines the steps for collecting and analysed and taking action on Customer Feedback.

Responsibility

The Estates Officer is responsible to ensure that this procedure is implemented. PROCEDURE 1. Customer Feedback is collected form a number of sources as follows:  Customer Complaints  Day to day dealing with the Customer.  Formal Customer Feedback. 2. Customer Complaints are handled as per the Corrective and Preventative action procedure No 304. 3. After a period of 3-9 months has passed on completion of a project, the Project Manager contacts the Client and together they complete a client feedback information. 4. The Client Feedback information is analysed and action taken accordingly if required, all action taken is recorded. 5. Results of the Client Feedback is fed into the Management Review Meeting for discussion. References: Customer Feedback Information. Management Review Procedure no 302

INTERNAL AUDITS PLAN 2009

HSE WEST ESTATES INTERNAL AUDIT SCHEDULE FROM JAN 09 TO JAN 10 UPDATED 15/12/08, UPDATED 19/3/09, UPDATED 9/5/09, UPDATED 20/5/09, UPDATED 14/6/09 COMPLETED OR STARTED. PLANNED AUDITS DATE TO BE AGREED SECTION

AREA

AUDITEE

AUDITOR

CAPITAL PROJECTS

REGIONAL HOSPITAL

JOE HOARE – PLASSEY

LOUISE NAUGHTON

MAINTENANCE

VARIOUS

REGIONAL HOSPITAL

LOUISE NAUGHTON

MONTH SCHEDULED

1 DAY – MAR 09

1 DAY – MAY 09

DATE COMPLETED Conducted 12TH May 09 to finalised june/ July 09

CONDUCTED 18TH May 09

NENAGH – JIM RYAN ENNIS – Jim Enright

1 DAY – SEPT 09 CONDUCTED June 09

1 DAY – june 09

FIRE SAFETY

PLASSEY

QUALITY MANAGEMENT

PLASSEY

CORPORATE MANAGEMENT FUNCTION

PLASSEY

QUALITY MANUAL PLASSEY

ISO 9001:2008 GAP AUDIT

PLASSEY

REVIEW OF MANAGEMENT

PLASSEY

BERNARD LENNON NIAMH MOOONEY

LOUISE NAUGHTON

1 DAY – APR 09

NIAMH MOOONEY

LOUISE NAUGHTON

1 DAY –MAR 09

LOUISE NAUGHTON

1 DAY – Nov 09

LOUISE NAUGHTON

1 DAY – OCT 09

JOE HOARE

NIAMH MOOONEY

NIAMH MOOONEY

NIAMH BERNARD AND JOE

LOUISE NAUGHTON

LOUISE NAUGHTON

Conducted 6th May 09 to finalise June/ July 09. COMPLETED 18th AND 19TH MARCH 09

1 DAY – MARCH 09 COMPLETED 19TH MAR 09

Nov 09

REVIEW SYSTEM

SGS EXTERNAL AUDITS – REVIEW at the Management Review Meeting

PLASSEY

SGS EXTERNAL AUDITS - REVIEW

PLASSEY

NIAMH BERNARD AND JOE

LOUISE NAUGHTON

1 DAY - JUN 09

NIAMH BERNARD AND JOE

LOUISE NAUGHTON

1 DAY - NOV 09

PLANNED 17TH JUNE 09

INTERNAL AUDITS 2009

ESTATES HSE WEST Audit Date: Audited Auditor: Auditee:

9th March 2009 Procedure: 301 Document and Date Control, dated 9/11/04, Revision 0 Louise Naughton Niamh Mooney

ref

question

Answer

1

Is the Master document list available to all Estates employees?

2

Is the Master document list up to date?

3

Are document changes controlled through the use of the corrective action form?

4.

Do all Estate staff have access by computer to the Estates procedures?

5.

Are records on the server backed up? Can changes to procedure

Currently a large job has been done on setting up all Estates documents on the server for all Estate staff to view. Yes the master document list was updated in March 09. A car is raised to control the updates to procedures. One will be raised to control update to procedure 301 to rev 1. Yes all Estates staff have computer access and will have access to procedures once these are set up on the server. Yes. Server is backuped up automatically every day. A “read only” will be set up

6.

Nc/obs Action planned By whom expected completion date

Closed out date and verification details

7.

only be controlled by the Quality Management Representative or delegate? Read and review the procedure are there other issues with the procedure.

for Estate employee to view documents. This is currently being set up. Reference are still made to Technical Services and Form no xxx.

obs

Remove references to Technical services and Form no xxx.

ESTATES HSE WEST Audit Date: Audited Auditor: Auditee:

th

9 March 2009 Procedure: 302 Management Review Procedure, dated 12/9/07, Revision 1 Louise Naughton Niamh Mooney

ref

question

Answer

1.

Is the Management Review Meeting conducted at defined intervals? Do all Managers or relevant employees attend the meeting Did the Management Review Meeting follow a set agenda? Were action items raised at the Management Review closed out.

Last Management Review Meeting conducted April 08. Next Due April 08

2.

3

4.

5.

Read the procedure and note any other issue with it.

Nc/obs Action planned By whom expected completion date

Yes Meeting attended by Gerry, Niamh Mooney and Louise Naughton. Yes. The agenda followed was the same as the previous year. The Management Review Meeting scheduled for April 09 will review the action items raised at the previous meeting. Reference are still being Obs made to Technical Services.

Remove these referenced.

Closed out date and verification details

ESTATES HSE WEST Audit Date: 9th March 2009 Audited Procedure: 303 Non Conforming control Procedure, dated 09/11/04, Revision 0 Auditor: Louise Naughton Auditee: Niamh Mooney ref question Answer Nc/obs Action planned By whom expected completion date 1. Are serious non Yes Customer Complaints conformities logged on and internal non the car form? Conformities are logged on the car files. 2. Are non conformities Yes. There are logged and details logged? followed up to completion by each area within Estates. 3. Are Car analysed and Yes. Last reviewed at the reviewed at the Management Review Management Review Meeting dated April 2008. meeting? 4. Are Non conformities The Car log shows that nc’s identified including have arisen form all these customer Complaints, sources. contractor issues, supplier issues, internal day to day activities. 5. Read the procedure and The procedure needs to be Obs. Update procedure to remove reference note any issues. reviewed to remove to Technical Services. references to Technical Services.

Closed out date and verification details

ESTATES HSE WEST Audit Date: 9th March 2009 Audited Procedure: 304 Corrective and Preventative Action , dated 09/11/04, Revision 0 Auditor: Louise Naughton Auditee: Niamh Mooney ref question Answer Nc/o Action planned bs By whom expected completion date 1. Are Corrective and Yes. CAR/PAR’s are raised Preventative actons logged on throughout the year 2007/8/9. the CAR/ PAR form? 2 Are all CAR/PAR’s logged on Yes. All CAR/PAR’s raised in the CAR/PAR log? 07/08/09 were logged on the CAR/PAR log. 3. Are CAR/PAR’s followed to Yes. The log is reviewed at completion by the least 3 times a year to ensure Management Representative or the action decided on is delegate? implemented and effective. 4. Are actions taken to address Yes. The log is reviewed at the car/par effective? least 3 times a year to ensure the action decided on is implemented and effective. 5. Is a review and analysis of all Yes. CAR/PAR are reviewed car/par carried out at the and analysed at the Management Review Meeting? Management Review Meetings last held April 08 April. 6. Read the procedure and note The procedure needs to be Obs. Update procedure to remove any issues. reviewed to remove references reference to Technical Services. to Technical Services.

Closed out date and verification details

ESTATES HSE WEST Audit Date: Audited Auditor: Auditee:

9th March 2009 Procedure: 305 Internal Audit Procedure, dated 09/11/04, Revision 0 Louise Naughton Niamh Mooney

ref

question

Answer

1.

Is an audit plan developed for the year? Are audits schedule on the basis of the importance of the area to be audit and on results of previous audit conducted in the area. Are the auditors independent of the areas being audited? Is an audit checklist used for the audit?

Yes. Internal Audit schedule in place for 2009. Yes. QMS and certain other procedures are scheduled to be audited once a year.

2.

3 4.

5

Is an audit trail maintained

6

If obs/ nc are identified are details of action to be taken decided on and a person assigned to take action?

Yes. External qualified consultant used to conduct internal audits. Yes. Standard audit checklist is prepared against each procedure this year. Yes. Audit trail maintained for each audit conducted on the QMS section this march. Yes. Actions to be taken are stated in the audit report of the march 2009 audits on the QMS.

Nc/o bs

Action planned By whom expected completion date

Closed out date and verification details

7

8 6.

Are nc/obs from internal audits Yes. Reviewed all old audit followed up to completion? reports and all obs/ ncs raised and signed off as complete. Is the full iso system audited at Yes. Reviewed the internal audit least once every two years? plan for 2009 Read the procedure and note The procedure needs to be any issues. reviewed to remove references to Technical Services.

Obs.

Update procedure to remove reference to Technical Services.

ESTATES HSE WEST Audit Date: 19th March 2009 Audited Procedure: 306 Quality Records Procedure, dated 09/11/05, Revision 0 Auditor: Louise Naughton Auditee: Niamh Mooney ref Question Answer Nc/o Action planned bs By whom expected completion date 1. Is there an Quality Records Yes there is a quality records Procedure in place as required procedure and it need updating to by ISO 9001:2008? remove references to Technical Services. 2. Is the CAR/PAR system used Yes, it is the system that will be to control the introduction and used if there are new quality revision to all quality records? records introduction or revision. 3 Is there a quality records Yes. Dated Jan 2006. listing in place? Does it cover retention times, responsibility, disposal filing and location of records? 4. Is the Quality Records listing Yes at the present time. up to date? 5 Are there any quality records None identified at present. not listed on the Quality records listing? 6. Read the procedure and note The procedure needs to be Obs. Update procedure to remove any issues. reviewed to remove references to reference to Technical Services. Technical Services.

Closed out date and verification details

HSE WEST ESTATES TH

Date: 19 MARCH 2009 Auditor: Louise Naughton Scope of Audit: BS EN ISO 9001:2008 Auditable changes Clause Number 4.2

4.1

Requirement

Objective Evidence

Are there references to ISO 9001: Checked Quality Policy, Quality Manual and Procedures. There are 2000. references in the Quality Manual and the Quality policy to ISO 9001:2000

The control over outsourced processes /sub contractors has /has not been considered in relation to  potential impact on achieving product conformity  capability of achieving control through application to clause 7.4  Extent to which control is

All project work is outsourced. There are detailed procedures in place on EU public Procurement that are followed. These procedure are in the existing Quality Management system and are audited. The is also a list of approved contractors maintained by John Magner.

Action to be taken by Whom and expected completion date. Update Quality Manual and the Quality Policy to remove referenced to ISO 9001:2000 and add references to ISO 9001:2008 Responsibility: Louise Naughton Expected completion Date: June 09 The approved Contractor list need to become a controlled document. Responsibility: Louise Naughton Expected completion Date: June 09

shared. 5.5.2

The managements representative is /is not a member of the organisations management

6.2.1

Competency of staff has /has not been established for all tasks that directly or indirectly affect conformity to product or service requirements

The HSE Estates West Officer Joe Hoare is the Management Representative for the QMS. This is stated in the Quality Manual section 5.5.2. and his responsibilities are stated. No action Required. Competency needs to be examined with Bernard and Joe.

Action Required: Examine competency requirements for all Estates staff. Assigned To: Bernard Lennon Expected Completion Date: June 2009

6.4

7.2.1

Work environment statement in the DQS does/does not relate to conditions under which work is performed and does/ does not include factors such as: noise, temperature, humidity, lighting or weather Scope of post delivery activities does /does not include : actions under warranty provisions, maintenance services, recycling, or

The HSE West Estates have a Safety, Health and Welfare Statement in place that is monitored and followed. No action Required.

Post Delivery activities do not form part of the contract agreements with Customer.

7.5.4

8.2.3

final disposals.

No action Required.

Intellectual property and personal data is /is not now considered a part of customer property.

Quality Manual section 7.5.4. checked. It refers to Confidential handling of customer information.

No action Required. The type and extent of monitoring or Entire Quality Management System. measurement is /is not appropriate to Adequate control are in place and each of the processes in relation to their documented and recorded for all stages impact on the conformity to product of the Service processes. requirements and on the effectiveness of the quality management system. No action Required.

ESTATES HSE WEST Audit Date: Audited Auditor: Auditee:

th

18 May 2009 Procedure: 101 Contingency Procedure Louise Naughton Tony Mc Bride.

ref

Question

answer

1.

Is the contingency Plan up to date?

2.

Is the plan available to each dept./ person who need it?

3.

Is the plan reviewed?

4.

Did the appropriate people in the organisation have input into the plan?

Yes. The plan is up to date. Dated 31st March 2005. The plan is available in the workshops in each location in a folder. The plan is reviewed when systems in place have changed. The systems in place have not changed so the there is no need to update the plan. Information was got from people

Nc/obs Action planned By whom expected completion date

Obs.

Re issue procedure at revision 1 to show that it was reviewed.

Closed out date and verification details

5.

6.

Is there a record of who in the department received training in the content of the procedure? Read and review the procedure are there other issues with the procedure.

concerned and incorporated into the plan? No record of training/ attendance in place. Reference are made to Technical Services.

Nc

Obs.

Review plan with appropriate people in the department and maintain attendance record. Remove reference to Technical Services form the procedure.

ESTATES HSE WEST th

Audit Date: 18 May 2009 Audited Procedure: 104 Procedure for maintenance plan march 2005 Auditee: Tony Mc Bride. ref Question Answer Nc/obs Action planned By whom expected completion date 1. Is there a maintenance plan available? Reviewed maintenance plan for 2009. Included is all 3 hospitals description of work, fire and safety, estates, location of work. 2. Is the plan issued out? This plan has been issued Jan 09 to the Manager - Mark Sparling, Estate Manager - Joe Hoare, 3. Was the plan approved? List and priorities are approved by Manager and Estates Manager. 4. Was the plan funded? Funding was sought

Closed out date and verification details

5.

Read and review the procedure are there other issues with the procedure.

by Joe Hoare from Estates Central. Correspondence has been received back on this through Joe. Funding still awaiting. Reference are made to Technical Services Supervisor and Officer.

Nc

Remove references to Technical Services.

ESTATES HSE WEST Audit Date: Audited Auditee:

th

18 May 2009 Procedure: 106 Procedure for Maintenance Request. Aug 04 rev 0 Tony Mc Bride.

ref

Question

Answer

1.

Are all calls routed through the Help Desk in the regional hospital?

2

Are all relevant details recorded on the system?

3.

Is a work order no allocated to each job?

4.

Are work orders issued to the foreman 3 times a day?

5.

Did the foreman review and report back to the help desk?

Yes all call go through the help desk. A standard template is used to record all details. Yes reviewed work codes allocated for last week. – ok Yes. The Forman receives work orders three times a day. Checked report 27/4/09- 14/5/09 Yes the Forman did report back to the help desk on status of the jobs for the

Nc/obs Action planned By whom expected completion date

Closed out date and verification details

6.

Was the backlog reviewed by T.S.S. Foreman?

7.

How are jobs issued to Croom And Maternity?

5.

Read and review the procedure are there other issues with the procedure.

Help desk to update the system. Yes the backlog was reviewed around every four months by Estates Forman. Job are faxed out to Nc Croom and the Maternity Hospitals. This control needs to be incorporated into the procedure. Reference are made Nc to Technical Services Foreman.

Job are faxed out to Croom and the Maternity Hospitals. This control needs to be incorporated into the procedure.

Remove references to Technical Services.

ESTATES HSE WEST th

Audit Date: 12 June 2009 Audited Procedure: 107 Procedure for staff Training revision 0 Auditor: Louise Naughton Auditee: Jim Enright Department. re Question Answer f 1. Review contents of the Procedure was reviewed by Jim procedure to ensure that the Enright and found to reflect procedure reflect staff training. practices. 2. Is there a designated Health Rodger Carey acting Forman is and Safety Rep? the Delegated Health and Safety Representative. 3. Are certificates of courses Yes Abrasive wheel training maintained on file? conducted 16/6/08 by Michael Brennan. 8 employees attended the course 4. Is mandatory training carried Yes, Safe pass, Abrasive wheels, out with staff? Fire and Safety training etc reviewed records on file and found ok. 5. Is the training matrix up to Reviewed the training matrix and date? found it to be up to date today. 6. Read and review the procedure Reference are made to Technical are there other issues with the Services. procedure.

Nc/ obs

Action planned By whom expected completion date

Closed out date and verification details

Obs .

Remove reference to Technical Services form the procedure. Item 4 makes reference to Technical

This was done and procedure now at rev 01 dated 12/6/09

Service.

ESTATES HSE WEST th

Audit Date: 12 June 2009 Audited Procedure: 108 Procedure for requesting Maintenance revision 0 Auditor: Louise Naughton Auditee: Jim Enright Department. ref Question Answer Nc/ Action planned obs By whom expected completion date 1. Are Maintenance request Yes all maintenance request are done by phone, email, fax. received by phone, fax or email. 2. Do the maintenance Reviewed Maintenance request request detail the following from Shannon social work dept, information include – dept, dated 4th feb 2008, request for location, requested by, date maintenance completed on 5/2/08 work requested, title and and signed off by foreman when phone number of completed. requester? 3. Do the Forman collect Yes. This is what happens work request every day? checked with Claire and Jim. 4. Did the foreman sign off Reviewed Request for the jobs as they are maintenance from Shannon completed? Health Centre dated 5/6/08, signed off by foreman when work complete. 5. Are the forms put up on the Yes. A spread sheet is maintained computer system? to log all maintenance requests reviewed today with Claire.

Closed out date and verification details

6.

7.

Is an annual report for Yes. Reviewed report 2008. 2008 drafted with summary of all Maintenance Request’s. Read and review the Reference are made to Technical procedure are there other Services. issues with the procedure.

Obs .

Remove reference to Technical Services from the procedure. There are reference to Technical Service.

This was done and procedure now at rev 01 dated 12/6/09

ESTATES HSE WEST Audit Date: Audited Auditor: Auditee:

th

12 June 2009 Procedure: 112 Hire of contract Labour on Day Works rev 0 Louise Naughton Jim Enright Department.

ref

Question

answer

1.

Review annual tenders from Contractors for hourly rates.

2.

Approval of evening and week end work using the “Hire of Contractors on Day Works Form” or a letter Memo.

Reviewed tenders for painting 16th Feb 2009. painting tenders issued and returned from 6 contractors, prices got back and tenders sorted according to price. Schedule of tenders received competed on HSE document and signed by Claire Killeen and Jim Enright on n10th Feb 2009 at 3.30pm Reviewed Hire of Contractors for Day work. Contractor – Joeseph and John Kiely electrical, date January 23rd 2009. Invoice matched to quote and on file. Request for approval form completed and approved by Care

Nc/obs Action planned By whom expected completion date

Closed out date and verification details

obs

This was done and procedure now at rev 01 dated 12/6/09

Include on item one of the procedure that request for Day works are also issued by email.

3. 4. 5.

6.

Are all Day Works recorded on the computer system? Is there an annual report compiled for Day Works? Match the Contractors invoice with a quotation and day works request?

Read and review the procedure are there other issues with the procedure.

Manager HSE. Yes, Excel spread sheet reviewed today for logging of Day Works. Yes. Reviewed annual report for Day Works today for year 2008. Reviewed Hire of Contractors for Day work. Contractor – Joeseph and John Kiely electrical, date January 23rd 2009. Invoice matched to quote and on file. Request for approval form completed and approved by Care Manager HSE. Reference are made to Technical Services.

Obs.

Remove reference to Technical Services form the procedure. Item no 2 on the procedure remove reference to A/TSS replace with Maintenance Manager

This was done and procedure now at rev 01 dated 12/6/09

MASTER DOCUMENT LIST

HSE MID-WESTERN AREA ISO MASTER DOCUMENT LIST LAST UPDATED 12th June 2009

Capital Projects Section Proc No 1 2&3 4 5 6 7 8 9 10 11

Procedure Title

Reviewed by

Authorised

Quality Manual Preparation of Project Briefs Does not Exist Engagement of Contractors and settlement of fees Does not Exist EU Public Procurement

Louise Naughton C Hanratty

C Hanratty 13/09/07 Helen Cuneen 28/02/05

2 0

C Hanratty

25/10/05

0

C Hanratty H Cunneen

Not completed 01/11/04

0 0

C Hanratty

T Mc Bride

09/08/04

0

C Hanratty H Cunneen

B Lennon B Ryan

11/04/05 06/09/05

0 0

Does not Exist Planning Permission Application Procedure Fire Certificate Application Procedure Preparation of design specification for equipment Does not exist

G Mc Namara

G Mc Namara G Mc Namara

Approval date

Rev.

12 13 14-16 17

Post Contract progress and Cost Control Equipping Procedure Does not exist Project Evaluation Stage 8 procedure

G Mc Namara H. Cuneen

18

Procedure for Control of Building Workmanship Appraisal of Capital Projects

19 20 21

Capital Projects Contract Award Procedure Control of Aspergillus During Construction Works

C Hanratty B Ryan

01/03/05 04/01/05

0 0

G Mc Namara

16/02/05

0

C Hanratty

T. McBride

20/04/05

C Hanratty

J.Mc Namara

14/09/06

C Hanratty

J.Mc Namara

14/09/06

C Hanratty

J.Mc Namara

14/09/06

0

C Hanratty

0 0 0

Maintenance Section Proc. Procedure Title No 101 Contingency Procedures (MWRH)

Reviewed by

Authorised

Approval date

Rev.

T Mc Bride

31/03/05

0

102

Asset Management Register - Estate

T Mc Bride

L Keehan/J Ryan L Keehan/J Ryan

09/08/04

0

103

Does Not Exist

104 105 106

Maintenance Plan Equipment Training Procedure Maintenance Request System

G.Mc Namara /H Cunneen T Mc Bride

107 108

Procedure for Staff Training (Clare) Procedure for Requesting Maintenance (Clare) Equipment Commissioning and Decommissioning Processing Maintenance Tasks (Tipperary) Procedure for Cleaning Shower Head Protocol Procedure in Respect of Hire of Contract Labour on Day Works (Clare) Management Of Hygiene Services

109 110 111 112 113

114 115

116

Medical Equipment Management Policy Procedure for Ordering Goods and Services and Payment on a weekly Basis (Tipperary) Procedure in Respect of Hire of Contracts Labour on Day Works – (Tipperary)

01/03/05 06/09/05 09/08/04

0 0 0

Clare Killeen Clare Killeen

C Hanratty G O Rourke L Keehan/J Ryan J.Mc Namara J.Mc Namara

12/06/09 12/06/09

1 1

Bernard Ryan

G O Rourke

09/01/06

0

Helen O’Toole

Jim Ryan

01/06/08

0

J.Mc Namara

J.Mc Namara

13/02/08

0

Jim Enright

Joe Hoare

14/06/09

1

Summer Meaney

07/2/08

0

Bernard Ryan Helen O’Toole

MW Hygiene Steering Committee J.Mc Namara J.Mc Namara

01/06/08 01/06/08

0 0

Jim Ryan

J.Mc Namara

01/06/08

0

Fire Safety Section Proc. Procedure Title No 201 Fire Prevention and Management in Buildings 202 Does Not Exist 203 Construction Safety Management

Reviewed by

Authorised

B Lennon /

204 205 206 207

Fire and Safety Training Does Not Exist Does Not Exist Fire and Safety maintenance programme

208

Control of Fire Hydrants

C Hanratty

209

Project for control of Aspergillus during construction Procedure for Prevention of Nosocomial Aspergillosis

C Hanratty

210

Quality Management Section

G MacNamara

Approval date 01/03/05

Revisi on 0

B. Lennon

11/7/05

0

B Lennon

G Mc Namara

04/03/05

0

G McNamara

C Hanratty (email)

11/07/05

0

11/09/07

2

11/08/04

0

27/04/05

0

C. Hanratty

C Hanratty

B Lennon G Mc Namara

G MacNamara

Proc. Procedure Title No 301 Document and Data Control 302 Management Review Procedure 303

Non Conformance Control

304

Corrective and Preventative Action

305 306 307

Internal Auditing Record Control Customer Feedback to be done

Reviewed by

Authorised J. Hoare J. Hoare

Approval date 09/04/09 09/04/09

L Naughton L Naughton /G Mc Namara L Naughton /B. Ryan L Naughton Namara L Naughton L Naughton L Naughton

Rev. 1 2

J. Hoare

09/04/09

1

J. Hoare

09/04/09

1

J. Hoare J. Hoare J. Hoare

09/04/09 09/04/09 01/02/09

1 1 0

Corporate Management Function Proc. Procedure Title No 401 Energy Management 402 Payments Procedure for technical services 403 Health Care Risk Waste Management 404 Procedure for Opening of Tenders

Reviewed to

Authorised by

G Mc Namara

T Mc Bride G Mc Namara

405

Low Value Purchases (Less than €1300)

Brian Long

406

Brian Long

408

Intermediate Value Purchases (>€1300 & €1300 &